Clinical outcomes after AF cardioversion in patients presenting left atrial sludge in trans-esophageal echocardiography.

BACKGROUND: Direct-current cardioversion (DCC) for atrial fibrillation carries a risk of stroke, probably associated with the temporary atrial stunning following cardioversion. The presence of a cardiac thrombus, usually localized in the left atrial appendage (LAA), is recognized as a clear contra-indication to the cardioversion. However, the presence of atrial sludge without LAA thrombus in trans-esophageal echocardiography (TEE) remains, for many cardiologists, a relative contra-indication to the cardioversion. The aim of this study was to evaluate the safety of DCC in patients presenting atrial sludge without LAA thrombus. METHODS: We prospectively included all consecutive patients demonstrating atrial sludge without LAA thrombus in TEE and undergoing DCC for persistent atrial fibrillation (AF). Safety of DCC was evaluated by the occurrence of clinical events at 1 month following cardioversion, i.e., up to the end of the atrial stunning period, as assessed by clinical examination and the standardized and validated Questionnaire for Verifying Stroke-Free Status (QVSFS). RESULTS: Over a period of 2 years, 21 patients presenting atrial sludge without LAA thrombus underwent DCC for AF. During the follow-up period of 1 month after DCC, no clinical embolic event, cardiac event, or unscheduled consultations/hospitalizations occurred. At 1 month, 67% of the patients remained in sinus rhythm. CONCLUSION: No clinical event occurred in patients demonstrating atrial sludge without thrombus and undergoing DCC for AF. These findings support current guidelines that only keep atrial thrombus as a contraindication to cardioversion, but warrant further investigation in large studies.

Transesophageal echocardiography for the assessment of left atrial appendage thrombus: Study of the additional value of systematic real time 3D imaging after regular 2D evaluation.

BACKGROUND: Two-dimensional transesophageal echocardiography (2DTEE) is currently validated for left atrial appendage (LAA) thrombus assessment but has some limitations. AIMS: To evaluate the performance and interest of systematic real time three-dimensional transesophageal echocardiography (3DTEE) for LAA thrombus assessment, when performed after 2DTEE. METHODS AND RESULTS: Consecutive patients undergoing TEE were prospectively included. LAA was first evaluated using 2DTEE, and patients were classified as "2D-NT" if no thrombus was found, "2D-T" in case of clear thrombus, or "2D-EQ" if equivocal. Then, 3DTEE of the LAA was performed and patients were similarly classified as "3D-NT," "3D-T," or "3D-EQ." Additional LAA CT scan was only performed if LAA thrombus was not clearly ruled out or confirmed by TEE. Additional value of 3DTEE after 2DTEE LAA evaluation was then assessed. We included 104 patients undergoing TEE. Agreement between 2DTEE and 3DTEE was very good for thrombus diagnosis (k = 0.936), but moderate for vacant LAA (k = 0.562) due to more frequent 2D-EQ than 3D-EQ (11.5% vs 2.9%; P = .016). 3DTEE allowed to refine the LAA status in 11 of 12 (91.7%) 2D-EQ patients: 10 3D-NT, 1 3D-T, and 1 3D-EQ. Coupling 3DTEE to 2DTEE permitted a definite LAA diagnosis in 103 of 104 (99%) vs 92 of 104 (88.5%) patients when 2DTEE was used alone (P = .002). Nine (8.7%) LAA thrombi were diagnosed, and 3 CT scan were performed. CONCLUSION: 3DTEE of the LAA is more effective for thrombus assessment than 2DTEE. 3DTEE should be particularly considered in case of equivocal 2DTEE, as it allows to reach a definite LAA diagnosis in almost all of the patients.